Neural Blockade in Clinical Anesthesia and Management of Pain, Volume 494
Intercostal nerve block
An intercostal nerve and its branches. Approximate area of skin supplied by bran ches is also shown. There is evidence, however, that local anesthetic injected n ear the lateral cutaneous branch diffuses posteriorly to reach the posterior cut aneous branch. Note also (i) the spinal nerves and dorsal root ganglia in the re gion of intervertebral foramen, with risk of perineurial spread into spinal fluo id after intraneural injection in this region; (ii) direct injection into an int ervertebral foramen may reach spinal fluid by means of dural cuff (iii) logal an esthetic may gain access to epidural space by diffusing into an intravertebral f oramen; and (iv) close to the midline the intercostal nerve lies directly on the posterior intercostal membrane and pleura. (v) Paravertebrally, solution may di ffuse to rami communicantes and symphatetic chain. Technique Technique Intercostal nerve block may be performed at several possible sites alo ng the course of the nerve. The most common, the posterior approach, offers seve ral advantages, and is perforemed at a site in the region of the angle of the ri bs just lateral to the sacrospinalis group of muscles, 7 to 8cm lateral of the m idline. At this location, the posterior intercostal membrane is impermeable. Lat eral to this, the internal inter-costal membrane becomes the internal intercosta l muscle which may permit local anesthetic solution to diffuse out of the interc ostal groove and into the external intercostal muscle. Furthermore, the ribs and intercostal spaces are thicker at the angle of the rib, allowing a larger margi n of safety, before pleura is contacted. For technical ease of performance and f or optimal teaching or learning experience, the patient is best placed ina Advanced Therapy in Thoracic Surgery edited by Kenneth L. Franco, Joe Billy Putnam Mechanism of action Intercostal nerve blocks produce analgesia by direct blockade of the intercostal nerves. There is usually minimal or no spread of anesthetic proximally to the d orsal rami of the intercostal nerves or the symphatetic chain. Contraindications There are no absolute contraindications specific to intercostal nerve blocks. Th e main relative contraindication of intercostal nerve blocks when used for post- thoracoctomy analgesia is in patients for whom the effects of high systematic bl ood levels of local anesthetic may be particulary detrimental, which includes pa tients which includes patients with cardiac conduction defects and seizure disor ders. Advantages and disadvantages ICNB require little training and no special equipment. The technique is quite sa fe, and any significant complication occurs within 30 minutes of performing the block. As such no special monitoring necessary for patients with these blocks be yond immediate post-block time period. The main disadvantages of intercostal blocks are the ncessity of performin separ ate blocks at multiple levels and the relatively short duration of analgesia ach ieved via the single-injection techniques.
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